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Dental Implant Malpractice Worries?
Robert, a dentist, informs us:
I am a general dentist who has carefully and responsibly and
successfully placed many dental implants over the past twenty years of
practice. This week, though, my life turned to hell.
Here´s the story: Patient is a 44 year old sweet woman. I surgically extracted broken lower 2nd molar on June 22, and decided on the spot to save her a second surgery. I placed two dental implants in extraction site, and a third in area of missing first molar. For years I have done every dental implant with a CT. This time, though, because the decision was on the spot and I wanted to save her a surgery, I relied on periapicals, i.e. pennicillin one week and dexamethasone 6mg/two days.
The night of the surgery when I called patient she reported pain, but it sounded typical, particularly because there was a surgical extraction also involved. Only 5-6 days after did she suddenly say, "..and it is still quite numb." The next day I sent her for a CT. When the CT was delivered to my office. I closed the door, sat down low because of fear of fainting, and my worst fears were realized: What I read as the ceiling of the mandibular canal was the floor. I had placed three dental implants squarely into the mandibular canal.
I found an oral surgeon who saw the films and advised to get them out as soon as possible. I immediately called the patient and she said that besides the total anesthesia of the right lip and chin area, she is having quite a lot of pain in the right incisor and lateral. I told her that "there is probably too much pressure" on the nerve, and she came in and I removed the three dental implants.
That was Friday June 30 (8 days after surgery). It is now a week later, however, her symptoms have not changed. I reassure her that it will return, but that patience is needed. The only thing that has changed is my wildly fluctuating blood pressure, pains, dizziness, nauseousnes!
What do I do now? Should I involve my insurance company at this point, or wait to see if there are changes? Would it be malpractice if I don't refer her to an oral surgeon now, or, because waiting is the only option now, that would just be pushing her into fear and into antagonism which she doesn't have yet? Do I need to say the words to her "I, the dentist who you so like and trust, the one who came so well recommended from so many of your friends in this small community, placed dental implants into your nerve and has most probably damaged you for life?"
Please help in any way. Are there any experts I should speak to? Is the pain in the incisors a sign of hope? Is there any way for me to help her? Is there any way out of this horrible mess for me personally without totally losing the trust and love of so many of my long term friends and patients that she is connected with?
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July 4, 2006 in Treatment Planning & Complications | Permalink
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Comments
Dear Dr. Robert
I am sorry to hear that 4th July weekend you are passing under such a stress.
It is possible that your drills have damaged inferior aleolar bundle.I am just suprised that you did not notice excessive bleeding.
I teach at institute and some times I find residents make mistake in reading fuzzy PAN-X SAME WAY during treatment planning.
In mandibular 2nd molar, canal is very close and it is not advisable to do immidiate implant plcement as you need to drill apical to socket for stability of implant UNLESS YOU HAVE ACCURATE KNOWLEDGE OF PROXIMITY OF CANAL.
This incident again stresses the importance of CT scan.
Any way damage has been done and IN MY OPINION, best thing to do is to consult neurologist(you are already in touch with OS)
and let him or her decide what is right thing to do instead of you deciding to wait and watch.As far as patient is concerned it is hard to explain such a terrible error.What are you gaining in not notifying your insurance company?It will be better to notify them, so you could have access to proper legal advice IN HANDLING the case.
Wish you good luck.
Posted by: satish joshi | Jul 4, 2006 12:48:34 PM
As far as pain in incisors area is concerened it may due to anastomosis from other side of mandible.
In your case extraction was involved so it was different story,but in case of implants placement in mandible I never use BLOCK anaesthesia.
I have learned this from Dr. Norman Cranin of MAXI course long time ago and I still follow it.
Posted by: satish joshi | Jul 4, 2006 1:00:19 PM
Dear Robert;
For the last ten years I have been an expert reviewer for dental malpractice cases in the state of Florida. There are several things you must do immediately. First is to contact your malpractice carrier to report the incident as a POTENTIAL for litigation. They will set up a file for you and assign an investigator. Next, you must collate all of your records. DO NOT add or delete anything within your chart other than describing your post-op care. Hopefully you have included informed consent as a part of your procedures. You may elect to refer to an appropriate specialist but, frankly, it will have little bearing on the initial steps that will be taken. That said, removal of the implants is the most prudent step you can take with the possible use of steroids. There is little else you can do other than letting nature take its course. After caring for your patient the best you can, your focus should be on protecting your well-being. You are not the first nor the last clinician that will be faced with this type of untoward consequence of treatment. With regard to the dysesthesia, it is certainly better than total anaesthesia in that there may be some undamaged fascicles within the nerve bundle. Hopefully there is a capacity to regenerate in this case.
Posted by: Robert J. Miller | Jul 4, 2006 1:47:14 PM
Did the patient have informed consent, and was parathesia, etc. mentioned? Was there a signed document?
These are some of the questions your liability co. will ask.
There are oral surgeons and others doing micro-surgery on mandibular nerve damage, I suggest you contact one and get an opinion quickly, as there are timely matters to be concerned about when repair is necessary. Make sure this Dr. will be your advocate.
Once you have done what you can, remember that these things happen, and go about living your life and doing your dentistry. "TURN IT OVER"
Posted by: Rob Pate, DMD | Jul 4, 2006 1:52:16 PM
For the benefit of your patient and you, refer the patient to one of the OMF surgeons who are known in the field of nerve injury. A neurologist wouldn' t be the first person I would refer to. It may be true that little could be done now, but since you are not a specialist in evaluating or treating nerve injuries, referring would be in the best interest of everyone involved.
An accurate diagnosis is needed for the degree of injury so that a reasonable prognosis could be given to the patient. Simplely reassuring the patient and wait is the wrong thing to do. CT or not is not the most important issue to deal with at this time.
Posted by: TW | Jul 4, 2006 2:30:43 PM
You must get a well respected surgeon who deals in nerve injury and microsurgery, and you must do it stat. Just think how badly you would look in court if you 'decided to let nature take it's course'.
Posted by: | Jul 4, 2006 2:31:39 PM
Anytime you "think" that there is a risk of malpractice, first action you must do is to report it and open up a case with your liability carrier. As much as terrible it might feel to you, this is your life and profession. You must lear from your mistakes, take more precautions from now on and lear to protect your patient and yourself better from now on. That does not mean that your intentions were bad, or you did not practice safe dentistry for your patients before. Any procedures we do, we can always do it better in this constantly changing environment.
Biggest issue here is your guilty feeling, your sense of wrong doing, your sense of failing and loss of respect for yourself. Don't beat up yourself my friend. I am sure, you have a family to support, employee's that depend on you for employment. Accidents happen and mistakes happen. You need to go on and place this behind you.
Professionally..you did the right action by removing implants but this should follow through with a referral to OS and truth about the procedure to the patient. Consult your carrier for advise and more than likely, sooner than later this will create unpleasant situations in your life but that will pass and life will go on.
More than anything, your family needs you. Good luck.
Posted by: | Jul 4, 2006 3:06:02 PM
I wish you a happy 4th, I know you cannot get this off your mind. I am a younger practitioner and have had 3 "legal events" in my career. 2 were bogus, and one was a real clinical judgement error.
The main thing to do is be compassionate and honest with your patient. Discuss this directly with her and do apologize for the adverse outcome. Be honest about the probable outcome (not too good). If you are honest, and refer her to excellent specialists, you have done ALL YOU CAN.
Once your patient calls an attorney, it is completely out of your hands. This is a common malpractice claim and this is exactly what you have malpractice insurance for!. Let your premiums do their work. I know (and you do too), that you do not do this on purpose, or because you were in a hurry or greedy. You were doing what we all do, trying to make a judgement to do the BEST thing for your patient. In hindsight, you would love to have made another choice.
Just be compassionate, honest, and remember the thousands of patients who worship the dentistry that you do. This patient will probably forgive you. *(the spouse will probably want to sue to get the $$, but you can't control that...) Best of luck.
I do all I can to avoid lawsuits, and if you have practiced so long without one, you are doing the same (talking to patients nicely etc.). However, once it is over, try to tell yourself that you cannot control what happens next (only attorneys arguing back and forth). It will take a long time to be "done", and you need to get some sleep. With heartfelt sympathy, enjoy the 4th- David
(PS feel free to email and you can call me to discuss further, I hope I can help).
Posted by: David | Jul 4, 2006 3:07:40 PM
I agree that you should inform your carrier ASAP and refer to a microneurosurgeon. If you email me I can give you some names. I think a neurologist may be called in later, but if a repair can be done, that would be best. I also agree to keep good and accurate records. if you treat the patient kindly and with care, chances are you will not be sued. I review many cases too and it is sually the people who do not refer and blow patients off that are the ones who get sued.
Posted by: Crystal Baxter DMD, MDS | Jul 4, 2006 3:07:40 PM
I am so sorry for the situation.
Legally seek advice from an experienced mal praxis specialist, delete nothing, omit nothing and disclose only what he tell you.
Clinically you are in real trouble, a neurologist of your trust might help you by prescribing her some high concentrates of b complex and some nerve regenerative stimulants in hope that it doesnt come to a total degeneration of the nerve so you wont need a supra specialist that will have to make a nerve graft (it is done in other parts of the body and it has began in the mouth as experiment in some countries)but if the patient has developed a painful disestesia (and it sounds like it)she might be forever in pain and so will you.
It is my most sincere hope that she recovers.
The best of luck
Posted by: Alejandro Berg | Jul 4, 2006 3:57:28 PM
The Implants MUST BE REMOVED. However, it may not be in your best interest to remove them yourself. (Playing devil's advocate... what if you have excessive/uncontrollable bleeding issues from the inferior alveolar artery? Can you manage it?) Get in touch with an Oral & Maxillofacial Surgeon ASAP. The surgeon should be one that you have a good working relationship with. If not, find one that will be your advocate during this matter. There is no question that a mistake was made but the fallout can be minimized. The #1 reason people get sued is other doctors saying "he did what to you?!...." A neurologist is not who you need to deal with now. You need to stick with someone who is an expert of the trigeminal nerve and that quite frankly is an OMFS.
Posted by: | Jul 4, 2006 4:26:14 PM
The Implants MUST BE REMOVED. However, it may not be in your best interest to remove them yourself. (Playing devil's advocate... what if you have excessive/uncontrollable bleeding issues from the inferior alveolar artery? Can you manage it?) Get in touch with an Oral & Maxillofacial Surgeon ASAP. The surgeon should be one that you have a good working relationship with. If not, find one that will be your advocate during this matter. There is no question that a mistake was made but the fallout can be minimized. The #1 reason people get sued is other doctors saying "he did what to you?!...." A neurologist is not who you need to deal with now. You need to stick with someone who is an expert of the trigeminal nerve and that quite frankly is an OMFS.
Posted by: | Jul 4, 2006 4:27:04 PM
Sorry to hear about the problem. Couple of thoughts:
1 What's done is done
2 Act in the best interest of your patient and refer to OMS for implant removal. You may only compound your damages if you continue to treat the patient.
3 REMOVE the word WILL from your vocabulary and replace with SHOULD - as in "sensation SHOULD (not WILL) return"
4 Never place an implant without appropriate clinical and radiographic documentation. A PA is never "appropriate radiographic documentation"
5 Never do ANY surgery without appropriate signed informed consent.
Sorry to hear about your troubles.
Best
David
Posted by: David Lambert | Jul 4, 2006 5:10:15 PM
I understand many clinicians either do not have CT / Tomo centers available to them, or the pan / PA is thought of as 'enough' but I applaud you for using tomo's as much as you describe - one case without wasn't the issue. It certainly takes a lot of concentration doing the surgeries and I think your case was just unlucky. It can happen just as easily doing exo's of deeply impacted 8's. I am new to surgeries, but my advice is get into another case and get your confidence back up, it is a huge learning curve we all know.
Posted by: | Jul 4, 2006 8:56:56 PM
Thank you so much Osseonews for posting my letter, and thank you to all the doctors who have responded with professional advise and with so much compassion. Today I will speak with my insurance company as advised. Ufortunately, due to the friendly and community nature of the relationship with most patients in general practice in my area, the vast majority of dentists ignore the advise of the insurance companies, and do not have patient sign any informed consent papers. Treatment just naturally flows from operative, C and B, into surgery if needed. Well, that works for most dentists, and worked for me just fine for 22 years, until now. I did not advise my patient of the dangers, and she signed nothing.
Is there any proven value in a B vitamin complex? For how long should she take it? She was on steroids(6mg dexamethasone) for 3 days after the original implant placement, and for two days after their removal. Should she continue a lower dose for a longer period to possibly help the damaged nerve or to relieve pain in the incisors? Is antibiotic coverage needed while taking the steroids? I have included my email here drrobert1@walla.com for further information/help from you that osseonews may decide not to include. thank you again.
Posted by: robert | Jul 4, 2006 9:41:17 PM
Dr. Robert Miller advised above that referral to a specialist at this time - a move I would prefer to avoid-is (medically and legally?)insignificant. Others have written that it should be done asap.
I understand that even if nerve microsurgery will be needed, a wait of about 3 months is indicated in order to see if there is natural healing, because the nerve surgery itself leaves a certain degree of damage. Thus how could a specialist help at this point now that the implants are out? Am I amiss medically or legally by putting that off at least for a few more weeks, or until I feel a need coming from the patient that she wants someone else to see her?
Posted by: robert | Jul 5, 2006 12:30:26 AM
The parethesia of the lip and chin will almost gone in 2 years we have the Facial and contralateral alveolar nerve. There a study in portugal of nerve regeneration using microsurgery and neuroblastoms, with good rate of success. If you have only a nerve membrane rupture or a swealling of the area if any doctor try to do something you will probably have a permanent damage. I advise you to wait 3 to 6 month to see, the schwan membranes of the nerv need this time to regenerate. I have 2 cases that heal completly in 2 and 4 month.
Posted by: ruipintocardoso | Jul 5, 2006 2:41:35 AM
The advice that the Facial Nerve or nerve fibers from the contralateral alveolar nerve will some how cause a return of function to the damaged Inferior Alveolar Nerve is very bad advice. Anatomically and neurophysiologically, this can not happen. The Facial Nerve will not provide any senory function in the area, it controls muscle movement. The contralateral Inferior Alveolar Nerve may have a slight about of crossover function, but not enough to provide normal feeling to the affected side.
It is in the patient's interest to see an Oral & Maxillofacial Surgeon experienced in nerve repair surgery. If surgery is indicated, the earlier it is done, the better chance the patient has for a good result.
Posted by: Steve | Jul 5, 2006 5:48:06 AM
One question that will probably surface is what would a reasonable dentist have considered absoltuely essential for diagnosis and tratment planning? A panoramic radiograph is superior to a periapical radiograph. Is the panoramic radiograph sufficent in cases like this involving mandibular posterior teeth?
Posted by: | Jul 5, 2006 5:54:53 AM
Am using a Treo 600 here so pls excuse broken wording...
1 Dexamethasone actually great idea initially to help deal w "compartment syndrome" like effect from nerve injury. Never heard anything about B Complex vits...
2 Concur w decision to refer to OMS. As an OMS myself it makes good sense to refer management to person who has experience in proper assessment. Furthermore if litigation occurs, you can bet a non-referral will be called into question. Kudos.
3 PA film is NEVER adequate. If you can't obtain proper imaging, DON'T DO SURGERY!!!!!
4 Pan will give you adequate info MOST of time. Advanced imaging only appropriate when panoramic info is inadequate or for osseous volume determinations, multiple implant placement, concerns foe pathology, angulation isssues etc. I probably refer less than 5 cases per year for CT imaging and IMHO is overused / a crutch.
5 Nerve recovery is variable and to certain degree age dependant. Problem here is you really don't know what type of injury you have - it could be a "simple" or "complex" compression nerve injury or a partial transection injury. Compression injuries don't always do well. Neither do partial transections - here you could get neuroma formation. If nerve was slightly squeezed (compression) that will probably recover. If segmnt of cortex was infractured this will require decompression and MAY never recover. Burning pain pt experiencing MAY represent early recovery but may also represent dysesthesia - this why referral to determine is so necessary. If impression is for recovery then proper dispensing of "tincture of time" is appropriate (approx 3 mo). If not and clinical/rad info suggests otherwise I would probably explore earlier rather than later. All the more reason for referral is important and appropriate.
best
DML
Posted by: David Lambert | Jul 5, 2006 7:17:13 AM
Contrary to other opinions there is NO guarantee there will EVER be complete nerve recovery. If anything it will probably be delayed (6 mo or more) and may be incomplete. How things progress is largely determined by the extent of injury - which none of us have the ability to determine.
One of the big mistakes made (IMHO) when a misadventure is referred is for referring doc to continue to try to steer the case after referral. My best advise to you and others is to turn over the drivers seat and stand on the sidelines - support your patient after referral but remember your continued involvement will only make resolving matters more difficult for your specialist to handle.
Best
DML
Posted by: David Lambert | Jul 5, 2006 7:49:29 AM
I can not believe that in this litigious society still there are communities like yours where dentists do not bother to take patient's consent.May be I have practiced my entire carrier in New York city.
Consent or no consent your case is very clear.
Best thing for you to keep very friendly cordial relations with your patient and treat her like you treat your family member.I am sure you would not wait if same thing happens to your loved one,I bet you will run to best specialist available.
So do same thing for your patient and she may reciprocate same way.
In any case what ever has happened, has happened.It is past.worry about present.
If you try to be honest and explained to other patints in your community they will understand.Accidents do occur.
You must not loose your confidence.
I do know one case just like yours and dentist did loose case but so what.Why do we pay for liability insurance anyway.Just take it easy and concentrate on the treatment of other patients or you may make error of different kind.
Good luck again.
Posted by: satish joshi | Jul 5, 2006 10:14:45 AM
from an OMS - you've gotten very good advice and have taken most of it - now dO the rest AND REFER THE PATIENT TO A LOCAL OMS -you are now (by your own admission)unequipped to manage this complication - the local OMS will then (if indicated) refer it to the nearest OMS who deals w/ nerve injuries - this referral is the best you can do at this point to protect yourself from
"failure to practice to the standard of care"
Posted by: | Jul 5, 2006 1:33:54 PM
You have my sympathy for the predicament you find yourself in. While some have said that a CT would have been helpful, I think that the problem resulted from two issues: You obviously used mandibular anesthesia to surgically remove the teeth. It's always beter to use infiltration anethesia when placing posterior implants. In that way when you encroach on the mandibular canal, the patient will feel it. I think it is always a good idea to take measurement X-rays when placing implants so that you can check on the direction and the proximity of the measurement post to the mandibular canal. Unfortunately, sometimes when you try to do a patient a favor (trying to avoid a second surgery) you hurt yourself more.
Stano
Posted by: | Jul 5, 2006 1:42:28 PM
Hi there,
I will not speak about the legal point of view, I will speak about the medical conduct after such an injury...
Loss of sensation could be permenant or temorary,, this depends on what kind of nerve injury we are speaking about, for instance, if you have a compressed nerve this means nerve recovery is fully expected within 14 days, if you have a partial nerve cut, then you have to expect 50-100% recovery within 3-6 months and for sure a complete nerve cut reduces expectations to 0% recovery.
If this happens with me, I will test sensation of the chin every 3 days with pin prick and touching the zone as well to evaluate any potential improvment making documented charts and taking photos everytime to compare and I will perscribe B Complex Vit (though this is debatable!) and dexomethasone locally.
A CT scan might be usefull to check the integrity of the nerve canal bony wall and evaluate what kind of injury you have, i.e crushed or compressed .. look on the relatively densed bone that surrounds the nerve usually !
I hope I was of a good help for you..
Posted by: Viva Portugal | Jul 5, 2006 2:58:14 PM
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